Gynecologic
Professionalism (appearance, eye contact, behavior) Explains task, assures confidentiality, obtains consent * Hello my name is [Medical Student] and I'm a first year medical student at [Medical School]. * Can I please get your full name and age please? * Miss. Doe, today my attending physician has asked me to take a history; I will be asking you a few question about your health, is that okay? * I just want to remind you that anything we discuss is confidential. * Is there anything you need before we get started? Begins with open ended questions and transitions * Miss Doe, what brings you in today? * Just to make sure I heard you correctly...*summarize* * Miss Doe, I'd like to ask you a few questions about your menstruation. Asks about age menarche, days of menstrual blood flow, cycle * How old were you when you first had your period? * How long is your menstruation cycle? * How long do your periods usually last? * How many pads or tampons do you use per day? * What color is the flow? * Asks about regularity in menses and LMP * Have you had any recent periods that were early or late? * Have you missed any periods in the past few months? * When was your last menstrual period? * Do you have any bleeding between your periods? * Is your menstruation painful? GP (term, preterm, abortions and living children) * GP ** G = Gavidia = total number of pregnancies ** P = Para = outcomes of the pregnancies * Have you ever been pregnant? ** How many times? ** How many living children do you have? ** Did you have any difficulties during pregnancy? ** Have you ever had a miscarriage or an abortion? *** How many times? * I get a better picture of what's going on, I'm going to be asking you some personal questions; is that okay? Asks about dyspareunia, dysmenorrhea * Miss Doe, are you sexually active right now? ** How many sexual partners do you have? ** What type of sex do you have? *** Vaginal, anal, oral sex. ** Do you use any contraception during sex? ** Are you trying to become pregnant or prevent pregnancy? ** Do you have a history of sexually transmitted infection? * Do you have any pain during intercourse? Asks about urinary incontinence if the patient has had children * Do you have any trouble controlling your bladder? Asks for dates and results of last cervical smear test & contraception use * When was your last cervical smear test? ** What was the result? Asks about vaginal discharge quantity, color, odor * Have you noticed any vaginal discharge? * How much discharge? * What color is it? * Is there an odor? ** What does the odor smell like? Summary presentation and communication skills * We have a 30 year white female that presented abdominal pain. Her menstration and family history is unremarkable. The patent states that she's sexually active with 3 partners and has a history of STI. Knowledge question